First, the nature of medical insurance determines the nature of medical reform, and the insurance nature of medical insurance determines that medical reform must introduce market mechanism;
Second, medical insurance is the basis of the formation of medical service price mechanism, and medical reform must give full play to the negotiation function of medical insurance;
Third, medical insurance provides a material basis for medical reform, and the sustainability of medical insurance fund must be maintained.
In order to lay a material foundation for medical reform, medical insurance first emphasizes the rationality of the material foundation and resolutely opposes the unreasonable requirements for the material foundation of medical insurance. Secondly, it is emphasized that the material basis of medical insurance should be sustainable, and the material basis of medical insurance cannot be proposed unilaterally. It is worth noting that the basic role of medical insurance is not equal to responsibility.
Since the plan and implementation plan for deepening the reform of medical and health system during the Twelfth Five-Year Plan period clearly put forward "giving full play to the basic role of universal basic medical insurance" for the first time, "the basic role of medical insurance" has appeared in policy documents many times, such as the summary of deepening the reform of medical and health system in 20 14 and the key tasks in 20 15. Notice of Ministry of Human Resources and Social Security on Doing a Good Job in Basic Medical Insurance for Urban Residents in 20 16 years (Ministry of Human Resources and Social Security Fa [2016] No.43), Guiding Opinions on Actively Promoting Medical Care, Medical Insurance and Medicine Linkage Reform (Ministry of Human Resources and Social Security Fa [2016] No.56) and
As an important institutional arrangement of national economic and social development, universal medical insurance is not only an important part of social security system, but also an important part of medical and health system, which has important institutional and basic functions in building a well-off society in an all-round way and promoting the strategy of "healthy China" (Wang Dongjin, 20 15). However, there are different opinions on how to play a fundamental role in theory and practice, and there are many misunderstandings among them. This paper aims to correct related misunderstandings and put forward three views on the basic role of medical insurance in medical reform.
The nature of medical insurance determines the nature of medical reform.
Since the establishment of China's modern medical insurance system, it is social insurance, not social welfare. The State Council's Decision on Establishing the Basic Medical Insurance System for Urban Employees (Guo Fa [1998] No.44) clearly stated that "the main task of the reform of the medical insurance system is to establish the basic medical insurance system for urban employees", that is, "to establish a social medical insurance system to guarantee the basic medical needs of employees". The Notice of the General Office of the State Council on Forwarding the Opinions of the Ministry of Health and Other Departments on Establishing a New Rural Cooperative Medical System (No.3 [2003] of the State Council) puts forward that the new rural cooperative medical system is a "medical mutual assistance and economic assistance system for farmers' serious illness as a whole", and mutual assistance and risk dispersion are the inherent requirements of the insurance system. Therefore, conceptually, the new rural cooperative medical system should also be an insurance system, not a welfare system. The Guiding Opinions of the State Council on Launching the Pilot Project of Basic Medical Insurance for Urban Residents (Guo Fa [2007] No.20) also put forward the idea of "establishing the basic medical insurance system for urban residents' serious illness as a whole".
The nature of medical insurance determines the nature of medical reform, and the direction of medical insurance determines the direction of medical reform. The insurance nature of medical insurance determines that medical reform must introduce market mechanism, give full play to the basic role of market in the allocation of medical resources, and cannot go back to the old road of planned economy. We emphasize encouraging and allowing all localities to actively explore medical reform, but all exploration cannot shake the basic premise of the nature of medical insurance or violate the basic laws of market economy.
In the practice of medical reform, there has always been a debate between third-party payment and "supporting two companies with one hand", the essence of which is to choose market mechanism or planned economy model. Giving full play to the basic role of medical insurance in medical reform is to give full play to the role of the third-party payment mechanism, rather than "supporting two companies with one hand". Some people may question this and think that the new medical reform plan puts forward the requirement of "strengthening government responsibility and investment" Does strengthening the third-party payment mechanism violate the requirement of "strengthening government responsibility and investment"? Third-party payment does not deny the government's responsibility, but emphasizes the introduction of market mechanism, with third-party payment subsidizing the demanders of medical insurance, while entrusting two medical institutions with one hand and directly subsidizing medical institutions to provide corresponding medical services, which is the old road of planned economy.
Medical insurance is the basis of forming medical service and drug price mechanism.
In the medical field, medical service and drug price mechanism should be formed by mutual consultation between buyers and sellers, not by the government. Giving full play to the basic role of medical insurance in medical reform is to give full play to the negotiation function of medical insurance as the representative of demand side, and lay the foundation for reasonable medical service and drug price formation mechanism through negotiations with medical institutions and drug suppliers.
Negotiation function is one of the basic functions of medical insurance. Theoretically speaking, medical insurance, as a big demand, should have strong negotiation ability and deterrence, which can effectively regulate and restrain the behavior of medical institutions and drug suppliers. However, in practice, the negotiation function of medical insurance failed to play a role. There are many reasons, for example, the current medical insurance agencies and medical insurance administrative departments are not divided, the medical insurance agencies are not independent legal persons, and they lack the motivation to actively search for relevant medical information to control medical expenses. But the fundamental reason is that the prices of medical services and drugs are not negotiated by buyers and sellers, but determined by government pricing. As a big demand, medical insurance failed to participate in the formation of medical services and drug prices.
In order to give full play to the basic role of medical insurance, we must adhere to the negotiation function of medical insurance and strengthen the negotiation power and capacity building of medical insurance. Therefore, it is necessary to (1) change the fragmented situation of employee medical insurance, new rural cooperative medical insurance and urban residents' medical insurance, strengthen the integration of basic medical insurance system and improve the overall efficiency of basic medical insurance. (2) Actively promote the "separation of management and operation" between medical institutions and health administrative departments, medical insurance agencies and medical insurance administrative departments, strengthen the independent legal person status of relevant market entities in the medical field, and strengthen the binding mechanism for independent legal persons to be responsible for their own profits and losses. Only when medical insurance institutions become independent market players, emphasizing the responsibility of medical insurance institutions to control fees will not become empty talk, and medical insurance institutions will have the incentive to actively collect relevant information, restrain the behavior of medical institutions and drug suppliers, and control the excessive growth of medical expenses. (3) Change the government pricing mechanism of medical services and drugs, change the state of separation of buyers and orderers in the past, actively explore the negotiation mode of medical insurance institutions directly participating in medical services and drug pricing, and form a price formation mechanism of tripartite negotiation among medical insurance, medical institutions and drug suppliers.
Medical insurance provides a material basis for medical reform.
Medical insurance provides a solid material foundation for medical reform. Relevant data show that in 20 1 1 year, the medical expenses paid by the medical insurance fund reached 61400 million yuan, and the total medical expenses of the insured accounted for 60%-70% of the total business income of medical institutions, and even reached 90% in some areas (Wang Dongjin, 20 12). Medical insurance fund has become the largest payer of medical institutions. The operation of medical insurance and the stability of medical insurance fund are directly related to the success or failure of medical reform and affect the trend of medical reform. If the medical insurance fund is in danger of collapse, the whole medical reform will stop or even go backwards. Therefore, to play the basic role of medical insurance in medical reform is to ensure the stable operation of medical insurance fund and ensure that the fund is not in danger.
There is a wrong view in practice that the reason why medical reform is unsuccessful is that the material foundation of medical insurance is not firm; To succeed in medical reform, it is necessary to establish a solid material foundation for medical insurance and increase the proportion of medical insurance reimbursement. In fact, the proportion of medical insurance reimbursement has reached 70%-80%, and even as high as 90% in some areas. The high reimbursement rate has seriously affected the security of the medical insurance fund, and the phenomenon of insufficient balance of the medical insurance fund or insufficient income in the current period has become more and more serious, which has seriously affected the health and sustainability of medical insurance.
There is also a wrong view that in order to promote graded diagnosis and treatment, we should further reform the medical insurance payment mechanism and increase the proportion of reimbursement for primary medical insurance. In fact, the graded diagnosis and treatment system has not been established, fundamentally because of the problems in the allocation of medical resources. The administrative control of medical resources leads to the growing scale and strength of medical institutions. For example, the First Affiliated Hospital of Zheng Da, known as the largest hospital in the world, has added 3,000 beds this year, although the Health Planning Commission strictly limits the number of hospital beds. The result of administrative control is that primary medical institutions are gradually hollowed out. The central government has been emphasizing that the grassroots are strong, but the grassroots are still weak and there are no good doctors. This is not because medical insurance is not enough to support primary medical institutions, but because there are too many administrative controls and the separation of multi-point practice and management is not done well.
In order to lay a material foundation for medical reform, medical insurance first emphasizes the rationality of the material foundation and resolutely opposes the unreasonable requirements for the material foundation of medical insurance. Secondly, it is emphasized that the material basis of medical insurance should be sustainable, and the material basis of medical insurance cannot be proposed unilaterally. To this end, first, we must determine a reasonable reimbursement ratio. Considering the contradiction between insurance and incentive, international experience shows that 75% reimbursement ratio can better coordinate the relationship between insurance and incentive; Second, we should design reasonable deductible line, capping line and payment method. We must realize that the basic function of medical insurance does not mean unlimited liability of medical insurance, which cannot and cannot bear all medical expenses.
The nature of medical insurance determines the nature of medical reform.
In practice, there is a view that the basic role is confused with the bottom responsibility, and it is believed that the bottom responsibility of medical insurance should be strengthened, especially in the problem of poverty caused by illness, the proportion of medical insurance reimbursement should be further increased, the deductible line of medical insurance should be lowered, the maximum payment limit should be raised, and the serious illness insurance system should be established to solve the problem of poverty caused by illness. Basic medical insurance is insurance, not assistance, not welfare. It is a mechanism to spread the risk of economic losses caused by diseases, not a system to eliminate poverty. Basic medical insurance emphasizes responsibility sharing, that is, individuals should bear certain responsibilities in financing and medical expenses, so that the insured can have the economic motivation to save medical insurance funds. Setting the minimum payment standard, reimbursement ratio and maximum payment limit of medical insurance is a concrete policy measure to implement responsibility sharing. Moreover, the minimum payment standard is not as low as possible, and the reimbursement ratio and the maximum payment limit are not as high as possible, otherwise it will inevitably lose the motivation to save fund resources and even lead to waste.
The basic function and the bottom responsibility are different and cannot be confused. Although basic insurance and bottom line are usually used together, they belong to different categories: basic insurance belongs to basic medical insurance and bottom line belongs to medical assistance; Basic medical insurance can only guarantee the basics, but it can't and can't guarantee the bottom line. In reality, the problems of poverty caused by illness and returning to poverty due to illness appear in large numbers. The reason is not that the basic function of basic medical insurance is not well played, but that the ability of medical assistance is not strong. The medical assistance project managed by the civil affairs department should bear the responsibility of poverty caused by illness and returning to poverty due to illness. However, the financial input is a drop in the bucket, which makes this bottom-up function far from being brought into play. To solve the problem of poverty caused by illness and returning to poverty due to illness, the government should increase the capacity building of social assistance such as medical assistance, rather than blindly emphasizing the basic role of medical insurance.
In short, a correct understanding of the basic role of medical insurance in medical reform requires that it can neither be belittled nor exaggerated, let alone belittle the basic role of medical insurance when fighting for power, and deliberately exaggerate the basic role of medical insurance when accusing. There is a tendency to exaggerate the basic role of medical insurance in practical work. Taking graded diagnosis and treatment as an example, there is a view that the graded diagnosis and treatment system has not been established because the basic role of medical insurance has not been played well and because the baton of medical insurance has not been played well. In fact, whether the baton of medical insurance can play a role is closely related to the reform of medical and health system and depends on the process of medical and health system reform.
Further reading: How to buy insurance, which is good, and teach you how to avoid these "pits" of insurance.